DIAGNOSING DIZZINESS IN THE EMERGENCY DEPARTMENT: Why “What do you mean by ‘dizzy’?” Should Not Be the First Question You Ask

DIAGNOSING DIZZINESS IN THE EMERGENCY DEPARTMENT: Why “What do you mean by ‘dizzy’?” Should Not Be the First Question You Ask

Author:

Newman-Toker, David Edward

Abstract:

Dizziness is a complex neurologic symptom reflecting a perturbation of normal
balance perception and spatial orientation. It is one of the most common symptoms
encountered in general medical practice. Considering the dual impact of symptom-related
morbidity (e.g., falls with hip fractures) and direct medical expenses for diagnosis and
treatment, dizziness represents a major healthcare burden for society. However, perhaps
the dearest price is paid by those individuals who are misdiagnosed, with devastating
consequences.
Dizziness can be caused by numerous diseases, some of which are dangerous and
manifest symptoms almost indistinguishable from benign causes. The risk appears
highest among patients with new or severe symptoms, particularly those seeking medical
attention in acute-care settings such as the emergency department. Nevertheless, even
acute dizziness is more often caused by benign inner ear or cardiovascular disorders.
Thus, a major challenge faced by frontline providers is to efficiently identify those
patients at high risk of harboring a dangerous underlying disorder.
Unfortunately, diagnostic performance in the assessment of dizzy patients is poor.
In part, this simply reflects the generally high rates of medical misdiagnosis encountered
in frontline settings. However, misdiagnosis of dizziness is disproportionately frequent.
Although possible explanations are myriad, I propose that an important cause stems from
the pervasive use of an antiquated, oversimplified clinical heuristic to drive diagnostic
reasoning in the assessment of dizzy patients. In this dissertation, I contend that the
commonly-applied bedside rule that dizziness symptom quality, when grouped into one
of four dizziness “types” (vertigo, presyncope, disequilibrium, or ill-defined dizziness), predicts the underlying cause, is false and potentially misleading. The argument
supporting this theory is developed in the chapters that follow.
Chapter 1 focuses on why dizziness diagnosis presents a significant challenge
worthy of our concerted attention. Chapter 2 describes a multi-institutional survey of
emergency physicians confirming that the “quality-of-symptoms” approach to dizziness
is the dominant paradigm for diagnosis. Chapter 3 describes a cross-sectional study of
emergency department dizzy patients demonstrating how this approach is fundamentally
flawed. Chapter 4 concludes with a discussion of why this flawed paradigm might have
garnered and maintained such widespread acceptance for over three decades.